Which intervention would the nurse implement to help prevent atelectasis?
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This guide has pneumonia nursing care plans and nursing diagnosis, nursing interventions, and nursing assessments for pneumonia. Nursing interventions for pneumonia and care plan goals for patients with pneumonia include measures to assist in effective coughing, maintaining a patent airway, decreasing viscosity and tenaciousness of secretions, and assisting in suctioning. Show
What is Pneumonia?Pneumonia is an inflammation of the lung parenchyma associated with alveolar edema and congestion that impair gas exchange. Pneumonia is caused by a bacterial or viral infection spread by droplets or by contact and is the sixth leading cause of death in the United States. The prognosis is typically good for people who have normal lungs and adequate host defenses before the onset of pneumonia. Pneumonia is a particular concern in high-risk patients: persons who are very young or very old, people who smoke, bedridden, malnourished, hospitalized, immunocompromised, or exposed to MRSA. Types of Pneumonia There are two types of pneumonia: community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP), known as nosocomial pneumonia. Pneumonia may also be classified depending on its location and radiologic appearance. Bronchopneumonia (bronchial pneumonia) involves the terminal bronchioles and alveoli. Interstitial (reticular) pneumonia involves an inflammatory response within lung tissue surrounding the air spaces or vascular structures rather than the area passages themselves. Alveolar (or acinar) pneumonia involves fluid accumulation in the lung’s distal air spaces. Necrotizing pneumonia causes the death of a portion of lung tissue surrounded by viable tissue. Pneumonia is also classified based on its microbiologic etiology – it can be viral, bacterial, fungal, protozoan, mycobacterial, mycoplasmal, or rickettsial. Aspiration pneumonia, another type of pneumonia, results from vomiting and aspiration of gastric or oropharyngeal contents into the trachea and lungs. Signs and Symptoms The main symptoms of pneumonia are coughing, sputum production, pleuritic chest pain, shaking chills, rapid shallow breathing, fever, and shortness of breath. If left untreated, pneumonia could complicate hypoxemia, respiratory failure, pleural effusion, empyema, lung abscess, and bacteremia. ADVERTISEMENTS Nursing care plan (NCP) and care management for patients with pneumonia start with assessing the patient’s medical history, performing a respiratory assessment every four (4) hours, physical examination, and ABG measurements. Supportive interventions include oxygen therapy, suctioning, coughing, deep breathing, adequate hydration, and mechanical ventilation. Other nursing interventions are detailed on the nursing diagnoses in the subsequent sections. Nursing Care Plans for PneumoniaHere are 11 nursing diagnoses common to pneumonia nursing care plans (NCP). They are as follows:
1. Ineffective Airway Clearance
ADVERTISEMENTS Ineffective Airway ClearanceIneffective Airway Clearance is a common NANDA-I nursing diagnosis for pneumonia nursing care plans. This diagnosis is related to excessive secretions and ineffective cough or nonproductive coughing. Inflammation and increased secretions in pneumonia make it difficult to maintain a patent airway. Nursing Diagnosis
Related FactorsThe following are the common related factors for the nursing diagnosis Ineffective Airway Clearance related to pneumonia:
Defining CharacteristicsHere are the common assessment cues that could serve as defining characteristics or “as evidenced by” for ineffective airway clearance secondary to pneumonia.
Desired OutcomesBelow are the common expected outcomes for ineffective airway clearance secondary to pneumonia:
Nursing Assessment and RationalesThe following nursing assessment for pneumonia and nursing interventions promote airway patency, increase fluid intake, and teach and encourage effective cough and deep-breathing techniques. 1. Assess the rate, rhythm, and depth of respiration, chest movement, and use of accessory muscles. 2. Assess cough effectiveness and productivity 3. Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes. 4. Observe the sputum color, viscosity, and odor. Report changes. 5. Assess the patient’s hydration status. Nursing Interventions and RationalesThis section contains ineffective airway clearance nursing interventions and actions for pneumonia and its rationales or scientific explanations. 1. Elevate the head of the bed and change position frequently. 2. Teach and assist the patient with proper deep-breathing exercises. Demonstrate proper splinting of the chest and effective coughing while in an upright position. Encourage the patient to do so often.
3. Suction as indicated: frequent coughing, adventitious breath sounds, desaturation related to airway secretions. 4. Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure). Offer warm, rather than cold, fluids. 5. Assist and monitor effects of nebulizer treatment and other respiratory physiotherapy: incentive spirometer, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate.
6. Encourage ambulation. 7. Administer medications, as indicated:
8. Use humidified oxygen or humidifier at the bedside. 9. Monitor serial chest x-rays, ABGs, and pulse oximetry readings. 10. Assist with bronchoscopy and thoracentesis, if indicated.
11. Anticipate the need for supplemental oxygen or intubation if the patient’s condition deteriorates. 12. Urge all bedridden and postoperative patients to frequently perform deep breathing and coughing exercises. ADVERTISEMENTS 1. Ineffective Airway Clearance
Previous Next Impaired Gas Exchange Related Nursing Care PlansOther nursing diagnoses you can use to craft another pneumonia nursing care plan.
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See AlsoOther recommended site resources for this nursing care plan:
Other nursing care plans related to respiratory system disorders:
References and SourcesRecommended journals, books, and other interesting materials to help you learn more about pneumonia nursing care plans and nursing diagnosis: Which intervention with the nurse implement to help prevent atelectasis in a client with a fractured ribs as a result of chest trauma?Incentive Spirometry and Deep breathing/coughing can help to open any collapsed alveoli and prevent further atelectasis. Incentive spirometry should be done every hour while awake. Patients with pulmonary contusions may decompensate on days 2 – 4.
How can atelectasis be prevented?To prevent atelectasis: Encourage movement and deep breathing in anyone who is bedridden for long periods. Keep small objects out of the reach of young children. Maintain deep breathing after anesthesia.
Which interventions will help prevent atelectasis postoperatively?Prophylactic maneuvers for reducing the incidence and magnitude of postoperative atelectasis in high-risk patients should be encouraged. These techniques are deep-breathing exercises, coughing exercises, and incentive spirometry.
What intervention should the nurse provide in order to prevent pneumonia and atelectasis?Supportive interventions include oxygen therapy, suctioning, coughing, deep breathing, adequate hydration, and mechanical ventilation.
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